Population-level effects of the national diabetes prevention programme (FIN-D2D) on the body weight, the waist circumference, and the prevalence of obesity

The Diabetes Prevention Gap And Opportunities To Increase Participation In Effective Interventions

To understand the current state of prediabetes burden and treatment in the US, we examined recent trends in prediabetes prevalence, testing, and access to preventive resources. We estimated 13.5 percent prevalence of diagnosed prediabetes in the overall US adult population, using national survey data. Although prediabetes prevalence increased by 4.8 percentage points from 2010 to 2020, access to preventive resources remained low. The most effective intervention for diabetes prevention, known as the National Diabetes Prevention Program, remained woefully undersupplied and underused. There are only 2,098 National Diabetes Prevention Program-recognized providers nationally, and only 3 percent of adults with prediabetes have participated in the program. We suggest three actions to augment prevention efforts: increase payment for prevention interventions to avoid supply distortions, improve data integration and patient follow-up, and extend coverage and broaden access for preventive interventions. These actions, which would require policy-level changes, could lower the barriers to prevention.

Healthcare Cost Development in a Type 2 Diabetes Patient Population on Glucose-Lowering Drug Treatment: A Nationwide Observational Study 2006-2014

OBJECTIVE

The objective of this study was to describe healthcare resource use and cost development in Sweden during 2006-2014 in a type 2 diabetes (T2D) population receiving glucose-lowering drugs (GLDs).

METHODS

In- and outpatient healthcare resource use and costs were extracted from mandatory national registries: the Cause of Death Register; the National Patient Register; and the Prescribed Drug Register. Primary care data were estimated based on an observational study including patients from 84 primary care centers in Sweden. Numbers of any cause inpatient, outpatient, and primary care contacts were extracted and direct healthcare costs were estimated.

RESULTS

During 2006-2014, the number of inpatient and primary care contacts increased by approximately 70% (from 45,559 to 78,245 and from 4.9 to 8.8 million, respectively) and outpatient care contacts almost doubled (from 105,653 to 209,417). Mean annual per patient costs increased by 13%, reaching €4594. Total healthcare costs increased from €835 million to €1.684 billion. Inpatient care costs constituted 47% of total costs in 2014 (€783 million), primary care accounted for 24% (€405 million), outpatient care 18% (€303 million), non-GLD medications 6% (€109 million), and GLDs 5% (€84 million). Cardiovascular diseases (CVDs) were the most costly disease group in inpatient care (26%), whereas managing unspecified factors influencing health and T2D-associated diseases were the most costly in outpatient care (16 and 11%, respectively).

CONCLUSIONS

The healthcare costs of the GLD-treated T2D population doubled during 2006-2014, mostly driven by the increasing size of this population, of which inpatient care accounted for 47%. GLDs constituted the smallest share of costs. CVD was the most resource-requiring disease group.

Effects of lifestyle changes on adults with prediabetes: A systematic review and meta-analysis

AIMS

To assess the efficacy, safety, and cost-effectiveness of lifestyle intervention, compared with treatment as usual in people with prediabetes as defined by the American Diabetes Association. For older studies, we used the 1985 World Health Organization definition.

METHODS

We systematically searched multiple electronic databases and referenced lists of pertinent review articles from January 1980 through November 2015. We performed an update search in MEDLINE on April 26, 2017. Based on a priori established eligibility criteria, we dually reviewed the literature, extracted data, and rated the risk of bias of included studies with validated checklists. To assess the efficacy of lifestyle intervention to prevent or delay further progression to type 2 diabetes, we conducted a random-effects meta-analysis. We assessed the certainty of evidence using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

RESULT

Pooled results of 16 randomized controlled trials showed that people with prediabetes who received lifestyle intervention had a lower rate of progression to type 2 diabetes after one (4% vs. 10%, RR 0.46 [CI 0.32, 0.66]) and three years of follow-up (14% vs. 23%, RR 0.64 [95% CI 0.53, 0.77]). The majority of the studies also showed a greater weight loss in lifestyle intervention participants, with a great variation between studies. Costs per quality-adjusted life-year were lower when the benefits of lifestyle intervention were analyzed over a lifelong time horizon compared to only the period of lifestyle intervention (three years) or to modeling over a ten-year period.

CONCLUSION

Lifestyle intervention is an efficacious, safe, and cost-effective measure to reduce the risk of progression to type 2 diabetes in people diagnosed with prediabetes. More research is necessary to compare the efficacy of various modes, frequencies, and intensities of lifestyle intervention across studies.

NHS Diabetes Prevention Programme in England: formative evaluation of the programme in early phase implementation

OBJECTIVES

Evaluation of the demonstrator phase and first wave roll-out of the National Health Service (NHS) Diabetes Prevention Programme (DPP) in England. To examine: (1) intervention design, provision and fidelity assessment procedures; (2) risk assessment and recruitment pathways and (3) data collection for monitoring and evaluation. To provide recommendations informing decision makers on programme quality, improvements and future evaluation.

DESIGN

We reviewed programme documents, mapping against the NHS DPP specification and National Institute for Health and Care Excellence (NICE) public health guideline: Type 2 diabetes (T2D) prevention in people at high risk (PH38), conducted qualitative research using individual interviews and focus group discussions with stakeholders and examined recruitment, fidelity and data collection procedures.

SETTING

Seven NHS DPP demonstrator sites and, subsequently, 27 first wave areas across England.

INTERVENTIONS

Intensive behavioural intervention with weight loss, diet and physical activity goals. The national programme specifies at least 13 sessions over 9 months, delivered face to face to groups of 15-20 adults with non-diabetic hyperglycaemia, mainly recruited from primary care and NHS Health Checks.

PARTICIPANTS

Participants for qualitative research were purposively sampled to provide a spread of stakeholder experience. Documents for review were provided via the NHS DPP Management Group.

FINDINGS

The NHS DPP specification reflected current evidence with a clear framework for service provision. Providers, with national capacity to deliver, supplied intervention plans compliant with this framework. Stakeholders highlighted limitations in fidelity assessment and recruitment and retention challenges, especially in reach and equity, that could adversely impact on implementation. Risk assessment for first wave eligibility differed from NICE guidance.

CONCLUSIONS

The NHS DPP provides an evidence-based behavioural intervention for prevention of T2D in adults at high risk, with capacity to deliver nationally. Framework specification allows for balance between consistency and contextual variation in intervention delivery, with session details devolved to providers. Limitations in fidelity assurance, data collection procedures and recruitment issues could adversely impact on intervention effectiveness and restrict evaluation.

Evaluation of a combined lifestyle intervention for overweight and obese patients in primary health care: a quasi-experimental design

BACKGROUND

Combined lifestyle interventions (CLIs) are designed to reduce risk factors for lifestyle-related diseases through increasing physical activity and improvement of dietary behaviour.

OBJECTIVE

To evaluate the effects of a CLI for overweight and obese patients on lifestyle-related risk factors and health care consumption, in comparison to usual care.

METHODS

Data on anthropometric and metabolic measurements, morbidity, drugs prescriptions and general practitioner (GP) consultations were extracted from electronic health records (timeframe: July 2009-August 2013). Using a quasi-experimental design, health outcomes of 127 patients who participated in a 1-year CLI were compared to a group of 254 matched patients that received usual care. Baseline to post-intervention changes in health outcomes between intervention and comparison group were evaluated using mixed model analyses.

RESULTS

Compared to baseline, both groups showed reductions in body mass index (BMI), blood pressure, total cholesterol and low density lipoprotein cholesterol in year post-intervention. For these outcome measures, no significant differences in changes were observed between intervention and comparison group. A significant improvement of 0.08 mmol/l in high density lipoprotein (HDL) cholesterol was observed for the intervention group above the comparison group (P < 0.01). No significant intergroup differences were shown in drugs prescriptions and number of GP consultations.

CONCLUSION

A CLI for overweight and obese patients in primary health care resulted in similar effects on health outcomes compared to usual care. Only an improvement on HDL cholesterol was shown. This study indicates that implementation and evaluation of a lifestyle intervention in primary health care is challenging due to political and financial barriers.

Successful up-scaled population interventions to reduce risk factors for non-communicable disease in adults: results from the International Community Interventions for Health (CIH) Project in China, India and Mexico

BACKGROUND

Non-communicable disease (NCD) is increasing rapidly in low and middle-income countries (LMIC), and is associated with tobacco use, unhealthy diet and physical inactivity. There is little evidence for up-scaled interventions at the population level to reduce risk in LMIC.

METHODS

The Community Interventions for Health (CIH) program was a population-scale community intervention study with comparator population group undertaken in communities in China, India, and Mexico, each with populations between 150,000-250,000. Culturally appropriate interventions were delivered over 18-24 months. Two independent cross-sectional surveys of a stratified sample of adults aged 18-64 years were conducted at baseline and follow-up.

RESULTS

A total of 6,194 adults completed surveys at baseline, and 6,022 at follow-up. The proportion meeting physical activity recommendations decreased significantly in the control group (C) (44.1 to 30.2%), but not in the intervention group (I) (38.0 to 36.1%), p<0.001. Those eating ≥ 5 portions of fruit and vegetables daily decreased significantly in C (19.2 to 17.2%), but did not change in I (20.0 to 19.6%,), p=0.013. The proportion adding salt to food was unchanged in C (24.9 to 25.3%) and decreased in I (25.9 to 19.6%), p<0.001. Prevalence of obesity increased in C (8.3 to 11.2%), with no change in I (8.6 to 9.7%,) p=0.092. Concerning tobacco, for men the difference-in-difference analysis showed that the reduction in use was significantly greater in I compared to C (p=0.014).

CONCLUSIONS

Up-scaling known health promoting interventions designed to reduce the incidence of NCD in whole communities in LMIC is feasible, and has measurable beneficial outcomes on risk factors for NCD, namely tobacco use, diet, and physical inactivity.

Smoking and weight among patients using clozapine

BACKGROUND

Both obesity and smoking are common in schizophrenia patients taking clozapine, causing cardiovascular disease and premature deaths.

METHODS

Two hundred and thirty-seven patients with schizophrenia or related psychoses treated with clozapine completed the Liverpool University Neuroleptic Assessment Scale (LUNSERS) and a questionnaire including current height, weight, changes therein and smoking status.

AIMS

The aim of this study was to analyze weight and weight change in smoking and non-smoking patients taking clozapine. A possible interaction between obesity and smoking was explored.

RESULTS

No association was found between weight change and smoking status during clozapine treatment. There was no significant difference in body mass index (BMI) between non-smokers and smokers. In the analysis of covariance (ANCOVA) with BMI as the dependent variable, the best fitting model comprised age, sex, intensity of sedation, and reported amount of smoking as explanatory variables (ηp(2)= 0.116; P = 0.029; power = 0.750). None of the explanatory proportions of any single factor was significant.

CONCLUSIONS

Estimated according to reported weight gain and BMI, no difference was found between smoking and non-smoking clozapine-treated patients. Number of cigarettes smoked explained BMI if age and sex were taken into account. This result is in line with the findings of some general population studies, where heavy smoking has been associated with a greater risk of obesity.

Trends in overweight and obesity over 22 years in a large adult population: the HUNT Study, Norway

Some reports indicate that the obesity epidemic may be slowing down or halting. We followed body mass index (BMI) and waist circumference (WC) in a large adult population in Norway (n = 90 000) from 1984-1986 (HUNT1) through 1995-1997 (HUNT2) to 2006-2008 (HUNT3) to study whether this is occurring in Norway. Height and weight were measured with standardized and identical methods in all three surveys; WC was also measured in HUNT2 and HUNT3. In the three surveys, mean BMI increased from 25.3 to 26.5 and 27.5 kg m-2 in men and from 25.1 to 26.2 and 26.9 kg m-2 in women. Increase in prevalence of obesity (BMI ≥ 30 kg m-2) was greater in men (from 7.7 to 14.4 and 22.1%) compared with women (from 13.3 to 18.3 and 23.1%). In contrast, women had a greater increase in abdominal obesity (WC ≥ 102 cm for men and WC ≥ 88 cm for women). There was a continuous shift in the distribution curve of BMI and WC to the right, demonstrating that the increase in body weight was occurring in all weight groups, but the increase of obesity was greatest in the youngest age groups. Our data showed no signs of a halt in the increase of obesity in this representative Norwegian population.

Using electronic medical records analysis to investigate the effectiveness of lifestyle programs in real-world primary care is challenging: a case study in diabetes mellitus

OBJECTIVE

The increasing prevalence of diabetes suggests a gap between real world and controlled trial effectiveness of lifestyle interventions, but real-world investigations are rare. Electronic medical registration facilitates research on real-world effectiveness, although such investigations may require specific methodology and statistics. We investigated the effects of real-world primary care for patients with type 2 diabetes mellitus (T2DM).

STUDY DESIGN AND SETTING

We used medical records of patients (n=2,549) with T2DM from 10 primary health care centers. A mixed-effects regression model for repeated measurements was used to evaluate the changes in weight and Hemoglobin A1c (HbA1c) over time.

RESULTS

There was no statistically significant change in weight (+0.07 kg, P=0.832) and HbA1c (+0.03%, P=0.657) during the observation period of 972 days. Most patients maintained their physical activity level (70%), and 54 % had an insufficient activity level. The variability in the course of weight and HbA1c was because of differences between patients and not between health care providers.

CONCLUSION

Despite effective lifestyle interventions in controlled trial settings, we found that real-world primary care is only able to stabilize weight and HbA1c in patients with T2DM over time. Medical registration can be used to monitor the actual effectiveness of interventions in primary care.